Evaluation of the national governmental efforts between 1997 and 2010 in reducing health inequalities in England

OBJECTIVES

The pandemic has compounded existing inequalities. In the UK, there have been calls for a new cross-government health inequalities strategy. This study aims to evaluate the effectiveness of national governmental efforts between 1997 and 2010, referred to as the National Health Inequalities Strategy (NHIS).

STUDY DESIGN

population-based observational study.

METHODS

Using Global Burden of Disease data, age-standardised years of life lost due to premature mortality (YLL) rates per 10,000 were extracted for 150 Upper Tier Local Authority (UTLA) regions in England for every year between 1990 and 2019. The slope index of inequality was calculated using YLL rates for all causes, individual conditions, and risk factors. Joinpoint regression was used to assess the trends of any changes which arose before, during or after the NHIS.

RESULTS

Absolute inequalities in YLL rates for all causes remained stable between 1990 and 2000, before decreasing over the following 10 years. After 2010, improvements slowed. A similar trend can be observed amongst inequalities in YLLs for individual causes, including ischaemic heart disease, stroke, breast cancer and lung cancer amongst females, and ischaemic heart disease stroke, diabetes and self-harm amongst males. This trend was also observed amongst certain risk factors, notably blood pressure, cholesterol, tobacco and dietary risks. Inequalities were generally greater in males than in females; however, trends were similar across both sexes. The NHIS coincided with significant reductions in inequalities in YLLs due to ischaemic heart disease and lung cancer.

CONCLUSIONS

The findings suggest that the NHIS coincided with a reduction in health inequalities in England. Policy makers should consider a new cross-government strategy to tackle health inequalities drawing from the success of the previous NHIS.

Barriers to conducting cancer trials in Canada: an analysis of key informant interviews

Background

In Canada, there is growing evidence that oncology clinical trials units (ctus) and programs face serious financial challenges. Investment in cancer research in Canada has declined almost 20% in the 5 years since its peak in 2011, and the costs of conducting leading-edge trials are rising. Clinical trials units must therefore be strategic about which studies they open. We interviewed Canadian health care professionals responsible for running cancer trials programs to identify the barriers to sustainability that they face.

Methods

One-on-one telephone interviews were conducted with clinicians and clinical research professionals at oncology ctus in Canada. We asked for their perspectives about the barriers to conducting trials at their institutions, in their provinces, and nationwide. Interviews were digitally recorded, transcribed, anonymized, and coded in the NVivo software application (version 11: QSR International, Melbourne, Australia). The initial coding structure was informed by the interview script, with new concepts drawn out and coded during analysis, using a constant comparative approach.

Results

Between June 2017 and November 2018, 25 interviews were conducted. Key barriers that participants identified were■ insufficient stable funding to support trials infrastructure and retain staff;■ the need to adopt strict cost-recovery policies, leading to fewer academic trials in portfolios; and■ an overreliance on industry to fund clinical research in Canada.

Conclusions

Funding uncertainties have led ctus to increasingly rely on industry sponsorship and more stringent feasibility thresholds to remain solvent. Retaining skilled trials staff can create efficiencies in opening and running studies, with spillover effects of more trials being open to patients. More academic studies are needed to curb industry's influence.

A new double crystal calibration system for absolute x-ray emission measurements down to ∼1 keV energies

Over the past few years, work has been conducted at AWE to accurately characterize x-ray diffraction crystals to allow for absolute measurements of x-ray emission for our Orion opacity campaigns. Diffraction crystals are used in spectrometers on Orion to record the dispersed spectral features emitted by the laser produced plasma to obtain a measurement of the plasma conditions. Previously, based on a Manson x-ray source, our calibration system struggled to attain a high signal at the low energies required in calibration for the use of aluminum as a tracer for higher atomic number experiments. Here, we present data from the newly commissioned CTX400 x-ray source, a twin anode water cooled system, showing it to be a bright source even for ∼1 keV energies. Rocking curve measurements for three of the most commonly used crystals, namely, pentaerythritol, cesium acid phthalate, and germanium, are presented for both convex and flat forms.

Development of Therapeutic Anti-JAGGED1 Antibodies for Cancer Therapy

The role of Notch signaling and its ligand JAGGED1 (JAG1) in tumor biology has been firmly established, making them appealing therapeutic targets for cancer treatment. Here, we report the development and characterization of human/rat-specific JAG1-neutralizing mAbs. Epitope mapping identified their binding to the Notch receptor interaction site within the JAG1 Delta/Serrate/Lag2 domain, where E228D substitution prevented effective binding to the murine Jag1 ortholog. These antibodies were able to specifically inhibit JAG1-Notch binding in vitro, downregulate Notch signaling in cancer cells, and block the heterotypic JAG1-mediated Notch signaling between endothelial and vascular smooth muscle cells. Functionally, in vitro treatment impaired three-dimensional growth of breast cancer cell spheroids, in association with a reduction in cancer stem cell number. In vivo testing showed variable effects on human xenograft growth when only tumor-expressed JAG1 was targeted (mouse models) but a more robust effect when stromal-expressed Jag1 was also targeted (rat MDA-MB-231 xenograft model). Importantly, treatment of established triple receptor-negative breast cancer brain metastasis in rats showed a significant reduction in neoplastic growth. MRI imaging demonstrated that this was associated with a substantial improvement in blood-brain barrier function and tumor perfusion. Lastly, JAG1-targeting antibody treatment did not cause any detectable toxicity, further supporting its clinical potential for cancer therapy.

Development of a T-cell Receptor Mimic Antibody against Wild-Type p53 for Cancer Immunotherapy

The tumor suppressor p53 is widely dysregulated in cancer and represents an attractive target for immunotherapy. Because of its intracellular localization, p53 is inaccessible to classical therapeutic monoclonal antibodies, an increasingly successful class of anticancer drugs. However, peptides derived from intracellular antigens are presented on the cell surface in the context of MHC I and can be bound by T-cell receptors (TCR). Here, we report the development of a novel antibody, T1-116C, that acts as a TCR mimic to recognize an HLA-A*0201-presented wild-type p53 T-cell epitope, p5365-73(RMPEAAPPV). The antibody recognizes a wide range of cancers, does not bind normal peripheral blood mononuclear cells, and can activate immune effector functions to kill cancer cells in vitroIn vivo, the antibody targets p5365-73 peptide-expressing breast cancer xenografts, significantly inhibiting tumor growth. This represents a promising new agent for future cancer immunotherapy. Cancer Res; 77(10); 2699-711. ©2017 AACR.

Engineering chimeric human and mouse major histocompatibility complex (MHC) class I tetramers for the production of T-cell receptor (TCR) mimic antibodies

Therapeutic monoclonal antibodies targeting cell surface or secreted antigens are among the most effective classes of novel immunotherapies. However, the majority of human proteins and established cancer biomarkers are intracellular. Peptides derived from these intracellular proteins are presented on the cell surface by major histocompatibility complex class I (MHC-I) and can be targeted by a novel class of T-cell receptor mimic (TCRm) antibodies that recognise similar epitopes to T-cell receptors. Humoural immune responses to MHC-I tetramers rarely generate TCRm antibodies and many antibodies recognise the α3 domain of MHC-I and β2 microglobulin (β2m) that are not directly involved in presenting the target peptide. Here we describe the production of functional chimeric human-murine HLA-A2-H2D^d tetramers and modifications that increase their bacterial expression and refolding efficiency. These chimeric tetramers were successfully used to generate TCRm antibodies against two epitopes derived from wild type tumour suppressor p53 (RMPEAAPPV and GLAPPQHLIRV) that have been used in vaccination studies. Immunisation with chimeric tetramers yielded no antibodies recognising the human α3 domain and β2m and generated TCRm antibodies capable of specifically recognising the target peptide/MHC-I complex in fully human tetramers and on the cell surface of peptide pulsed T2 cells. Chimeric tetramers represent novel immunogens for TCRm antibody production and may also improve the yield of tetramers for groups using these reagents to monitor CD8 T-cell immune responses in HLA-A2 transgenic mouse models of immunotherapy.

Calibration of X-ray spectrometers for opacity experiments at the Orion laser facility (invited)

Accurately calibrated and characterised x-ray diagnostics are a key requirement in the fielding of experiments on the Orion laser where absolute measurements of x-ray emission are used to underpin the validity of models of emissivity and opacity. Diffraction crystals are used in spectrometers on Orion to record the dispersed spectral features emitted by the laser produced plasma to obtain a measurement of the plasma conditions. The ability to undertake diffraction crystal calibrations supports the successful outcome of these Orion experiments. This paper details the design and commissioning of a system to undertake these calibrations in the energy range 2.0 keV to approximately 8.5 keV. Improvements to the design are detailed which will extend the commissioned range of energies to below 1 keV.

Abstract C128: Development of therapeutic anti-Jagged1 monoclonal antibodies

Background: The Notch pathway is an evolutionarily conserved cell-signaling system that plays an important role in both physiologic and pathologic conditions such as embryonic development and cancer. In the latter, Notch signaling has been reported to promote tumor growth by regulating different aspects of tumor biology such as cell survival, proliferation, angiogenesis, and stemness. Because of its importance, targeting of this pathway has been attempted via both small molecules (γ-secretase inhibitors; GSIs) and neutralizing antibodies (against individual Notch receptors or DLL4 ligand) but limitations still hamper the clinical use of such therapeutics, generally due to pathway complexity and toxicities caused by complete pathway inhibition (GSIs). Targeting Notch ligands such as Jagged1 (JAG1), offers the opportunity to selectively block specific elements of the pathway important in tumor biology thus avoiding normal tissue toxicities.

Methods: Structural studies defined a region of JAG1 (DSL + EGF1-3) that bound Notch1, which was used as an immunogen. Using classical hybridoma technology we have generated and subsequently characterised a panel of monoclonal antibodies (mAbs) against the JAG1 ligand, both in vitro (cell signaling and cell biology assays) and in vivo (tumor xenografts in both mice and rats).

Results: Four functional blocking mAbs recognised a unique JAG1 epitope within its DSL domain binding interface with Notch1, effectively blocking ligand-receptor interaction in vitro. Importantly, our mAbs were cross-reactive with rat Jag1 but not the murine orthologue. These were able to inhibit endogenous JAG1-induced signaling in tumor and stromal cells (eg. vascular smooth muscle cells). JAG1 mAb treatment reduced in vitro breast cancer 3D growth, exhibiting reduced expression of important genes such as HES1, IL6 and decreased numbers of cancer stem cells. Treatment did not affect JAG2-induced growth, or signaling mediated by other Notch ligands (eg. DLL4), confirming mAb specificity. Importantly, JAG1 mAb treatment in vivo inhibited Notch signaling and tumor growth in cancer xenograft models in two different host animals. Host body weight, blood tests and histological analysis detected no toxicity.

Conclusions: We generated neutralizing mAbs able to inhibit JAG1-induced signaling both in vitro and in vivo. The ability of JAG1 blockade to impair tumor growth without toxicity indicates it has the potential to make a contribution to the current arsenal of cancer therapeutics. This mAb treatment will be subjected to further in vivo testing, both alone and in combination with other therapeutic approaches, to further expand our knowledge of its clinical potential and mechanism of action.

Funding and conflicts of interest

This work is supported by Cancer Research UK and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre Programme. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

We have filed a patent application, WO/2014/111704, claiming therapeutic use of the JAG1 antibodies.

Citation Format: Massimo Masiero, Demin Li, Pat Whiteman, Carol Bentley, Jenny Greig, Tasneem Hassanali, Sarah Watts, Stephen Stribbling, Jenna Yates, Ji-Liang Li, Susan Mary Lea, Penny Ann Handford, Adrian Llewellyn Harris, Alison Hilary Banham. Development of therapeutic anti-Jagged1 monoclonal antibodies. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr C128.

A soft x-ray transmission grating imaging-spectrometer for the National Ignition Facility

A soft x-ray transmission grating spectrometer has been designed for use on high energy-density physics experiments at the National Ignition Facility (NIF); coupled to one of the NIF gated x-ray detectors it records 16 time-gated spectra between 250 and 1000 eV with 100 ps temporal resolution. The trade-off between spectral and spatial resolution leads to an optimized design for measurement of emission around the peak of a 100-300 eV blackbody spectrum. Performance qualification results from the NIF, the Trident Laser Facility and vacuum ultraviolet beamline at the National Synchrotron Light Source, evidence a <100 μm spatial resolution in combination with a source-size limited spectral resolution that is <10 eV at photon energies of 300 eV.

Influence of chylomicron remnants on human monocyte activation in vitro

BACKGROUND AND AIMS

Atherosclerosis is known to be an inflammatory disease and there is increasing evidence that chylomicron remnants (CMR), the lipoproteins which carry dietary fats in the blood, cause macrophage foam cell formation and inflammation. In early atherosclerosis the frequency of activated monocytes in the peripheral circulation is increased, and clearance of CMR from blood may be delayed, however, whether CMR contribute directly to monocyte activation and subsequent egress into the arterial wall has not been established. Here, the contribution of CMR to activation of monocyte pro-inflammatory pathways was assessed using an in vitro model.

METHODS AND RESULTS

Primary human monocytes and CMR-like particles (CRLP) were used to measure several endpoints of monocyte activation. Treatment with CRLP caused rapid and prolonged generation of reactive oxygen species by monocytes. The pro-inflammatory chemokines MCP-1 and IL-8 were secreted in nanogram quantities by the cells in the absence of CRLP. IL-8 secretion was transiently increased after CRLP treatment, and CRLP maintained secretion in the presence of pharmacological inhibitors of IL-8 production. In contrast, exposure to CRLP significantly reduced MCP-1 secretion. Chemotaxis towards MCP-1 was increased in monocytes pre-exposed to CRLP and was reversed by addition of exogenous MCP-1.

CONCLUSION

Our findings indicate that CRLP activate human monocytes and augment their migration in vitro by reducing cellular MCP-1 expression. Our data support the current hypothesis that CMR contribute to the inflammatory milieu of the arterial wall in early atherosclerosis, and suggest that this may reflect direct interaction with circulating blood monocytes.

Context-dependent cell cycle checkpoint abrogation by a novel kinase inhibitor

Background

Checkpoint kinase 1 and 2 (Chk1/Chk2), and the Aurora kinases play a critical role in the activation of the DNA damage response and mitotic spindle checkpoints. We have identified a novel inhibitor of these kinases and utilized this molecule to probe the functional interplay between these two checkpoints.

Principal Findings

Fragment screening, structure guided design, and kinase cross screening resulted in the identification of a novel, potent small molecule kinase inhibitor (VER-150548) of Chk1 and Chk2 kinases with IC₅₀s of 35 and 34 nM as well as the Aurora A and Aurora B kinases with IC₅₀s of 101 and 38 nM. The structural rationale for this kinase specificity could be clearly elucidated through the X-ray crystal structure. In human carcinoma cells, VER-150548 induced reduplication and the accumulation of cells with >4N DNA content, inhibited histone H3 phosphorylation and ultimately gave way to cell death after 120 hour exposure; a phenotype consistent with cellular Aurora inhibition. In the presence of DNA damage induced by cytotoxic chemotherapeutic drugs, VER-150548 abrogated DNA damage induced cell cycle checkpoints. Abrogation of these checkpoints correlated with increased DNA damage and rapid cell death in p53 defective HT29 cells. In the presence of DNA damage, reduplication could not be observed. These observations are consistent with the Chk1 and Chk2 inhibitory activity of this molecule.

Conclusions

In the presence of DNA damage, we suggest that VER-150548 abrogates the DNA damage induced checkpoints forcing cells to undergo a lethal mitosis. The timing of this premature cell death induced by Chk1 inhibition negates Aurora inhibition thereby preventing re-entry into the cell cycle and subsequent DNA reduplication. This novel kinase inhibitor therefore serves as a useful chemical probe to further understand the temporal relationship between cell cycle checkpoint pathways, chemotherapeutic agent induced DNA damage and cell death.

Characterization of Cardiac Brain Natriuretic Peptide Release in Patients With Paroxysmal Atrial Fibrillation Undergoing Left Atrial Ablation

Background— Paroxysmal atrial fibrillation (PAF) is associated with elevated levels of brain natriuretic peptide (BNP). The exact cardiac source and implications of this are currently unknown, as are the effects of left atrial ablation on cardiac BNP release. We sought to investigate BNP levels at different cardiac sites in PAF patients before and after left atrial ablation and compare these with a non–atrial fibrillation control cohort.

Methods and Results— Twenty PAF patients (52�10 years, 70% men; left ventricular ejection fraction, 55�3%) undergoing ablation were studied, BNP levels were measured at different cardiac sites before and after ablation and compared with a control cohort undergoing ablation for left lateral accessory pathways (10 patients, 41�11 years; left ventricular ejection fraction, 55�4%). In both cohorts, the coronary sinus BNP levels were the greatest. The PAF cohort had significantly greater BNP levels than the control cohort at all sites before and after ablation. Ablation of the left atrium was associated with a significant decrease in coronary sinus BNP levels ( P =0.05) and transcardiac BNP gradient ( P =0.03). This was not observed in the control cohort.

Conclusions— BNP levels are elevated in PAF, with the highest levels in the coronary sinus. Ablation of the left atrium was associated with an immediate decrease of BNP levels, implicating this as the source.

The Influence of Adaptation on Visual Motion Detection in Chronic Sixth Nerve Palsy After Treatment with Botulinum Toxin

PURPOSE

To investigate changes in visual motion perception after treatment with botulinum toxin in patients with unilateral chronic lateral rectus muscle palsy.

METHODS

Five patients and control subjects were asked to report the perceived drift direction of a sinusoidal grating that was initially stationary and then began to accelerate at 0.09 degrees /sec2 in a horizontal direction. The grating had a field size of 18.5 degrees and was presented monocularly with a contrast just above threshold for visibility for central vision. Both the paretic and non-affected eyes were tested. Psychophysical testing was performed under the following conditions: 1) before treatment and testing, patients occluded their paretic eye for at least three days to avoid diplopia. 2) After treatment with botulinum toxin, alignment was corrected and patients stopped occluding their paretic eye for at least three days before testing. The control subjects occluded their non-dominant eye for three days before testing.

RESULTS

In condition 1, no differences in motion detection values between patients and control subjects were found. In condition 2, motion detection thresholds were raised approximately 0.15 degrees /sec as compared to pre-treatment values and compared to the control group.

CONCLUSIONS

After treatment, a raised threshold for motion detection is one mechanism used to avoid oscillopsia and visuo-vestibular disorientation during head movements in patients with chronic paralytic squint. This study lends evidence that perceptual-adaptive, compensatory mechanisms develop to reduce oscillopsia and disorientation rather than being caused by abnormal cortical motion processing or defective eye muscle action.

Transient treatment with CDK inhibitors eliminates proliferative potential even when their abilities to evoke apoptosis and DNA damage are blocked

Transient treatment with small molecule CDK inhibitors is toxic to cancer cells and leads to depletion of anti-apoptotic proteins and Chk1, coupled with DNA damage and induction of apoptosis. Here we have examined, which of these phenomena are necessary for CDK inhibitors to have an anti-proliferative effect. We find that 24 hours treatment with either a primarily CDK2-specific, or a primarily CDK7/9-specific, antagonist eliminates proliferative potential even if apoptosis is blocked and the tendency of CDK inhibition to result in DNA damage is overcome by expression of recombinant Chk1. Loss of proliferative potential is correlated with irreversible suppression of biomarkers of cell cycle progression. CDK inhibitors dramatically reduced levels of the anti-apoptotic proteins, Mcl-1 and XIAP, but siRNA-mediated suppression of Mcl-1 and XIAP did not induce cell death in the osteosarcoma cells used in this study. Finally, we found that many literature CDK inhibitors do not effectively suppress the CDK/cyclin complexes responsible for cell cycle progression at the minimum doses required to block proliferation: some are only effective after a substantial delay and may act via inhibition of CDK7.

Dietary fats induce human monocyte activation in vitro

In early atherosclerosis the frequency of activated monocytes in the peripheral circulation is amplified, and migration of monocytes into the walls of the aorta and large arteries is increased, due partly to de novo expression or activation of monocyte adhesion molecules. Although there is increasing evidence that CMRs (chylomicron remnants) are strongly atherogenic, the outcomes of interactions between blood monocytes and circulating CMRs are not known. Here, we have studied the effects of CRLPs (CMR-like particles) on THP-1 human monocyte oxidative burst. The particles induced a significant increase in reactive oxygen species within 1 h, which persisted for 24 h. We suggest that monocyte–CMR interactions may be important in early atherosclerosis when many activated monocytes are found in susceptible areas of the artery wall.

An audit of the process of developing the Health Improvement Programme into the Strategic and Financial Framework in two Health Authorities

Health Improvement Programmes (HImPs) are a means of documenting the health needs of a population and are intended to be translated into commissioning decisions by the Strategic and Financial Framework (SaFF). This paper examines some major influences on the process of translating the HImP into the SaFF. The Directors of Public Health in two Health Authorities were concerned that the development of the SaFF did not always represent a clear progression from the HImP. An audit to pinpoint where commissioning decisions did not match the identified health improvement needs in two Health Authorities was carried out between November 2000 and February 2001. The overall findings confirmed that needs identified in the HImPs were not fully reflected in the service provision described in the final SaFFs. The audit provided evidence that was useful in identifying major issues and influences that facilitated or hindered the development of the SaFF from the HImP. Some of the ways in which HImP priorities disappeared from the SaFF and non-HImP priorities appeared in it were also distinguished. The conclusion is that a clear, criterion-based process should enable health and social care communities and Primary Care Trusts to develop a more responsive commissioning process in future, and specific recommendations to that effect are made.

Nightguard vital bleaching: a long-term study on efficacy, shade retention. side effects, and patients' perceptions

BACKGROUND

The scientific literature is lacking in long-term clinical data on the duration of efficacy and post-treatment side effects of nightguard vital bleaching.

PURPOSE

This longitudinal clinical study was undertaken (1) to determine the clinical efficacy and duration of efficacy at 3, 6, and 47 months post treatment of a peroxide-containing whitening solution; (2) to evaluate safety issues with respect to using a peroxide whitening solution; and (3) to determine patients' perceptions of the whitening technique.

MATERIALS AND METHODS

This project was part of a nightguard vital bleaching study involving human participants. The study teeth for efficacy and duration of efficacy when using a 10% carbamide peroxide solution were the four maxillary central and lateral incisors, with the tooth shade being taken from the middle third of the tooth. Safety issues evaluated were the changes in gingival index (GI), plaque index (PI), nonmarginal gingival index (NMGI), nongingival oral mucosal index (NGOMI), and tooth vitality (TV). Radiographic changes of the study teeth and the patients' perceptions of tooth sensitivity (TS) or gingival irritation (Girr) during treatment and post treatment were also evaluated.

RESULTS

The active 10% carbamide peroxide whitening solution used in this study was effective in lightening teeth (98%), and this effect was sustained at a mean of 47 months post treatment in 82% of the participants. When evaluating safety issues, 66% of the participants using the active solution reported TS or Girr. No one reported TS or Girr or any other adverse effects at the end of the study.

CONCLUSIONS

The results of this study concur with those of previously reported studies that nightguard vital bleaching using a 10% carbamide peroxide whitening solution according to the manufacturer's instructions is efficacious and safe, with minimal side effects. In addition, long-term shade retention was reported by 82% of the participants at the end of the study, with no adverse side effects.

CLINICAL SIGNIFICANCE

Results of this study should reassure dentists that nightguard vital bleaching is a safe, effective, and predictable method to lighten teeth. The whitening effect lasted up to 47 months in 82% of the patients, with no adverse side effects reported at the end of the study.

Squint surgery in the over sixties

We examined the indications for strabismus surgery in patients 60 years of age or older. A retrospective review was carried out of 111 case records of such patients operated on between January 1992 and May 1999. There were 59 females and 52 males, ranging in from 60 to 90 years (mean 67.3 years). The diagnoses were varied: the largest groups were cranial nerve palsies and consecutive strabismus. Fifty-six patients demonstrated binocular potential pre-operatively and 60 post-operatively. Twenty-three patients underwent reoperation. Twenty-eight patients also received botulinum toxin. The mean follow-up was 15 months, 54 patients were discharged within 6 months. Elective strabismus surgery in this age group constituted 7% of strabismus surgery activity (single surgeon). There were no complications. There is a demand for strabismus surgery in this ever increasing age group.

Adjustable squint surgery in children

The adjustable suture technique in adult strabismus surgery is well established. The aim of this study was to assess its feasibilty/outcome in a younger age group. A retrospective review of 359 case notes of patients, under the age of 16 years, who underwent squint surgery between 1992 and 1999 was carried out. Of these, 45 (13%) had undergone surgery with the adjustable suture technique. Post-operatively, 34 patients achieved an angle of +/- 10 pd and required no further treatment. We sought co-operation from the parents and encouraged their active participation during adjustment. It was not necessary for any child to return to the operating theatre to finalise adjustment. We conclude that this is an effective treatment in motivated children, as 76% (34/45) obtained an excellent result.

Estimating the impact on prostate cancer mortality of incorporating prostate-specific antigen testing into screening

OBJECTIVES

Whether early detection using prostate-specific antigen (PSA) and digital rectal examination (DRE) compared with DRE alone will reduce prostate cancer mortality awaits the results of ongoing prospective randomized trials. However, the impact that early detection could have on prostate cancer-specific survival can be estimated by assuming that PSA failure after radical prostatectomy (RP) will translate into death from prostate cancer.

METHODS

The study population consisted of 1274 men with clinically localized prostate cancer who underwent RP in Boston, Massachusetts or Philadelphia, Pennsylvania between 1989 and 2000 and had a preoperative PSA level greater than 4 but not more than 10 ng/mL. The primary endpoint was actuarial freedom from PSA failure (defined as PSA outcome).

RESULTS

The relative risk of PSA failure after RP for patients diagnosed with a PSA of greater than 4 to 5, 5 to 6, 6 to 7, or 7 to 8 ng/mL compared with greater than 8 up to 10 ng/mL was 0.3 (95% confidence interval [CI] 0.2 to 0.5), 0.5 (95% CI 0.4 to 0.8), 0.6 (95% CI 0.4 to 0.9), or 0.9 (95% CI 0.6 to 1.3), respectively. On the basis of the estimates of the 5-year PSA outcome, patients with a biopsy Gleason score of 5 or 6 (781 of 1274; 61%) consistently benefited from RP performed when the PSA at diagnosis was greater than 4 to 7 ng/mL compared with greater than 8 to 10 ng/mL (93% versus 78%, P <0.0001). A benefit to early detection was not found for the vast majority (266 of 312; 88%) of patients who had a biopsy Gleason score of 7 or higher.

CONCLUSIONS

Early detection using both PSA and DRE-based screening may benefit men who present with biopsy Gleason score 5 or 6 prostate cancer and a PSA level greater than 4 to 7 ng/mL compared with greater than 8 up to 10 ng/mL. This finding awaits validation from ongoing prospective randomized trials.

Bioabsorbable implants in orthopaedics: new developments and clinical applications

The use of bioabsorbable implants in orthopaedic surgical procedures is becoming more frequent. Advances in polymer science have allowed the production of implants with the mechanical strength necessary for such procedures. Bioabsorbable materials have been utilized for the fixation of fractures as well as for soft-tissue fixation. These implants offer the advantages of gradual load transfer to the healing tissue, reduced need for hardware removal, and radiolucency, which facilitates postoperative radiographic evaluation. Reported complications with the use of these materials include sterile sinus tract formation, osteolysis, synovitis, and hypertrophic fibrous encapsulation. Further study is required to determine the clinical situations in which these materials are of most benefit.

Quantitation of vital bleaching by computer analysis of photographic images

BACKGROUND

The authors investigated the use of computer processing of photographic images to monitor changes in tooth brightness after nightguard vital bleaching, or NGVB.

METHODS

Photographs of shade guides and clinical cases (patients' teeth) were taken on 35-millimeter film with electronic flash illumination and processed commercially. A slide scanner was used to digitize images as red, green and blue, or RGB, files, with constant brightness, contrast and linearity settings; the images were then analyzed with commercial software. Relevant image components (that is, teeth or shade guide tabs) were separated, and histograms of various numerical color descriptors were generated for each image component.

RESULTS

Analysis of shade tab images showed that the mean pixel intensity for the RGB blue channel, or MPIb, was the most satisfactory brightness descriptor, with clear sequential MPIb increments from lighter to darker shades in each series of colors (A through D) and close correlation with the manufacturer's brightness scale (r = .83). Mathematical analysis of MPIb data for shade tabs in the same image yielded a brightness index that was reproducible and correlated well with the manufacturer's brightness scale. Sequential measurements of this index in three subjects whose teeth were bleached with carbamide peroxide for 14 days correlated well with assessments made by visual shade guide comparisons.

CONCLUSIONS

The authors conclude that computer analysis of digitized photographic images with internal color controls provides an index of tooth brightness that is reproducible from image to image.

CLINICAL IMPLICATIONS

A brightness index derived from computer analysis of digitized photographic images may be useful for monitoring the effectiveness of NGVB.

Ocular abnormalities in Alagille syndrome

OBJECTIVE

To assess the type and frequency of ocular abnormalities occurring in Alagille syndrome (AS) in a large group of affected patients and their parents and the potential pathogenetic role of fat-soluble vitamin deficiency.

DESIGN

Observational case series.

PARTICIPANTS

Twenty-two children with AS and 23 of their parents participated.

MAIN OUTCOME MEASURES

Participants underwent full ophthalmic examination, including refraction, orthoptic examination, keratometry, slit-lamp examination, and funduscopy. Corneal diameter measurement was performed in a subset of nine and fluorescein angiography in a subset of six. Serum levels of vitamins A and E and cholesterol were measured.

RESULTS

The most common ocular abnormalities in patients with AS were posterior embryotoxon (95%), iris abnormalities (45%), diffuse fundus hypopigmentation (57%, a previously unreported finding), speckling of the retinal pigment epithelium (33%), and optic disc anomalies (76%). Microcornea was not associated with large refractive errors, and visual acuity was not significantly affected by these ocular changes. Vitamin levels were normal. Ocular abnormalities including posterior embryotoxon, iris abnormalities, and optic disc or fundus pigmentary changes were detected in one parent in 36% of cases.

CONCLUSIONS

Alagille syndrome is associated with a characteristic group of ocular findings without apparent serious functional significance and probably unrelated to fat-soluble vitamin deficiency. Simple ophthalmic examination of children with neonatal cholestatic jaundice and their parents should allow early diagnosis of AS, eliminating the need for extensive and invasive investigations.

The management of lymph node tuberculosis notified in England and Wales in 1993

We have compared the management of 219 cases of lymph node tuberculosis reported to the 1993 national notification survey with the recommended standards of treatment. The diagnosis was supported by positive histology and bacteriology in 81 cases (37%), positive histology in 70 (32%), positive bacteriology in 26 (12%), and on only clinical grounds in 40 (18%). Most patients (88%) were under the care of thoracic physicians. Almost all (97%) were commenced on a recommended drug combination, but only 81% continued to receive it, with thoracic physicians more likely than other physicians to use a recommended combination. Non-standard durations of the initial and/or continuation phases of treatment were used in 83 patients, but in only 49 cases was a satisfactory reason given for the modification. Definite or suspected drug toxicity was reported in 22 cases (10%), and was significantly more likely with non-standard regimens. There were no deaths. Of the 209 patients observed to treatment completion, 129 (62%) were then discharged. There were adequate reasons for follow-up after the end of treatment in all but 32 (15%) of those so managed. Further education is required to increase the percentage of patients treated with evidence-based regimens and durations of chemotherapy.

The management of pulmonary tuberculosis notified in England and Wales in 1993

We have compared the management of 925 cases of pulmonary tuberculosis reported to the 1993 national tuberculosis notification survey with the recommended standards of treatment. Forty-eight per cent of patients were white, 36% came from the Indian subcontinent (ISC) and 15% were of other ethnic origin. Most patients (86%) were under the care of thoracic physicians. Sputum microscopy was positive in 44%, and culture confirmation was obtained in 64% of cases. Drug resistance was reported in 30/582 isolates (5%), ranging from 13% in Black-Africans to 4.5% in ISC ethnic groups and 2% in the whites, with none reported in those of Black-Caribbean origin. Almost all patients (94.5%) were started on a recommended drug combination, but only 74% continued to receive one, with thoracic physicians significantly more likely than other physicians to use a recommended combination. Non-standard durations of either initial and/or continuation phase therapy were used in 303 patients, but in only 167 was a satisfactory reason given for the modification. Definite or suspected drug toxicity was reported in 79 (9%) and was significantly more likely with non-standard regimens. Seventy-two patients died before the survey was carried out one year after their notification, only 15 of them directly due to tuberculosis. Of the 815 cases observed to treatment completion, 430 (53%) were then discharged. There were adequate reasons for follow-up after the end of treatment in all but 98 of those so managed. Although the results were satisfactory overall, continued efforts are required to increase the percentage of patients treated with evidence-based recommended regimens and durations of chemotherapy.

A randomized study of the influence of perfusion technique and pH management strategy in 316 patients undergoing coronary artery bypass surgery. I. Mortality and cardiovascular morbidity

The impact of perfusion technique and mode of pH management during cardiopulmonary bypass has not been well characterized with respect to postoperative cardiovascular outcome.

METHODS

This double-blind, randomized study comparing outcomes after alpha-stat or pH-stat management and pulsatile or nonpulsatile perfusion during moderate hypothermic cardiopulmonary bypass was undertaken in 316 patients undergoing coronary artery bypass operations.

RESULTS

Cardiovascular morbidity and mortality were not affected by pH management, and the incidence of stroke (2.5%) did not differ between groups. Overall in-hospital mortality was 2.8%, eight of the nine deaths occurring in the nonpulsatile group (5.1% versus 0.6%; p = 0.018). The incidence of myocardial infarction was 5.7% in the nonpulsatile group and 0.6% in the pulsatile group (p = 0.010), and use of intraaortic balloon pulsation was significantly more common in the nonpulsatile group (7.0% versus 1.9%; p = 0.029). The overall percentage of patients having major complications was also significantly higher in the nonpulsatile group (15.2% versus 5.7%; p = 0.006). Duration of cardiopulmonary bypass, age, and use of nonpulsatile perfusion all correlated significantly with adverse outcome.

CONCLUSIONS

Use of pulsatile perfusion during cardiopulmonary bypass was associated with decreased incidences of myocardial infarction, death, and major complications.

A randomized study of the influence of perfusion technique and pH management strategy in 316 patients undergoing coronary artery bypass surgery. II. Neurologic and cognitive outcomes

This double-blind, randomized comparison of pulsatile or nonpulsatile perfusion and alpha-stat or pH-stat management during cardiopulmonary bypass was designed to assess postoperative central nervous system outcomes.

METHODS

Neurologic and cognitive testing was conducted before the operation and 7 days and 2 months after the operation in 316 patients having coronary artery bypass and in a reference cohort of 40 patients having major vascular and thoracic operations.

RESULTS

As detailed in part I of this study, mortality in patients having coronary bypass was 2.8%. The incidence of stroke was 2.5% and did not differ among bypass groups. Mortality was 2.5% for the major surgery cohort. The incidence of cognitive (p = 0.003) and either neurologic or cognitive dysfunction (p = 0.0002) was higher at 7 days for the coronary bypass group than for the major surgery cohort. The incidence of neurologic dysfunction remained higher (p = 0.050) at 2 months in the coronary bypass group. Cognitive dysfunction at 2 months was less prevalent after 90 minutes of cardiopulmonary bypass in patients managed with alpha-stat than with pH-stat strategy (27% versus 44%, p = 0.047).

CONCLUSIONS

Postoperative central nervous system dysfunction is more prevalent in patients having coronary bypass than in those having major operations. Pulsatility has no effect on central nervous system outcomes, but alpha-stat management is associated with a decreased incidence of cognitive dysfunction in patients undergoing prolonged cardiopulmonary bypass.

Antipodal alpha-N-(methyl through decyl)-N-normetazocines (5,9 alpha-dimethyl-2'-hydroxy-6,7-benzomorphans): in vitro and in vivo properties

The enantiomeric (-)- and (+)-N-(methyl through decyl) normetazocines (5,9 alpha-dimethyl-2'-hydroxy-6,7-benzomorphans) were synthesized and their in vitro and in vivo activities determined. Increasingly bulky enantiomeric N-alkyl homologs were prepared until their interaction with the sigma 1 receptor decreased and their insolubility became a hindrance to their evaluation in vivo and/or in vitro. The (-)-methyl, -pentyl, -hexyl, and -heptyl homologs were essentially as potent as, or more potent than, morphine in the tail-flick, phenylquinone, and hot-plate assays for antinociceptive activity; the (-)-propyl homolog had narcotic antagonist activity between that of nalorphine and naloxone in the tail-flick vs morphine assay, and it also displayed antagonist properties in the single-dose suppression assay in the rhesus monkey. The antinociceptively potent (-)-heptyl homolog did not substitute for morphine in monkeys but did show morphine-like properties in a primary physical-dependence study in continuously infused rats. All five potent compounds showed high affinity for the mu opioid receptor from both rat and monkey preparations and the kappa opioid receptor (< 0.05 microM), and all except the (-)-methyl homolog interacted reasonably well at the delta receptor (K(i) < 0.1 microM). The (-)-propyl compound was equipotent (K(i) 1.5-2.0 nM) at mu and kappa receptors. The pattern of interaction of the (-)-enantiomeric homologs with mu receptors from rat and monkey preparations was similar, but not identical. The enantioselectivity of the homologs for mu receptors was greater in the rat than in the monkey preparation for all but the N-H and butyl compounds, and the enantioselectivity of the lower homologs (methyl through butyl) for the mu (monkey) receptor was greater than for the kappa or delta receptors. However, bulkier homologs (hexyl through decyl) displayed higher enantioselectivity at kappa or delta receptors than at the mu (monkey) receptor. The (+)-butyl through (+)-octyl homologs were essentially equipotent with, or more potent than, (+)-pentazocine at the sigma receptor. Only the (+)-H and (+)-methyl homologs had high affinity (< 0.05 microM) at PCP binding sites.

Reasons for restoration replacement: differences in practice patterns

Patients receive varying types and amounts of restorative treatment, depending on the prescribing dentist. The aim of this study was to enhance the understanding of the variation of the restoration replacement practices of dentists. Three dentists in private practice in similar semirural communities with comparable practice demographics were asked to gather data on all restorations they replaced over a period of 1 month. They recorded the tooth number, number of restored surfaces, restorative material being replaced, number of surfaces in the replacement restoration, the replacement restorative material, and the reasons for the replacement restoration. Statistically significant differences were found among the dentists as to the reasons for posterior restoration replacement, replacement materials used, and increase in size of the replacement restorations. Differences were attributed to individual practice philosophies, demonstrating that clinical information was not the sole determining factor as to type of replacement restorations that patients received.

Primary health care in northwestern Somalia: a case study

This paper examines the problem of initiating health care programmes in areas where there is no effective infrastructure. The problem is examined using Northwestern Somalia as a case study. The project focussed on the establishment of well-trained and well-supported CHWs at the community level. Many of these communities are (semi-)nomadic. The roles of middle-level management staff, community leaders and committees, CHW remuneration and health effects of the project are discussed.

Analytical and physiological variability of salivary microbial counts

Quantitation of mutans streptococci (MS) and Lactobacillus has been proposed as a method for the identification of patients at high risk for dental caries. The purpose of the present study was to investigate the analytical and physiological variability of this procedure. Variability due to specimen collection and processing was investigated by repeated sampling studies. Sample stability was investigated over storage periods of up to 72 hr at 5 degrees C, room temperature, and 37 degrees C. Physiological variability was investigated by performance of serial analyses on ten individuals, who collected six samples at intervals on a single day, and rising and noon samples on ten subsequent days. Sample collection, rather than sample processing, was found to be the major factor determining the imprecision of salivary microbial analysis in the majority of cases. However, individual subjects varied considerably in the consistency with which they provided saliva samples. Imprecision due to sample processing was relatively small, with coefficients of variations of 2.3% for MS counts and 2.1% for Lactobacillus counts. Samples were generally stable over a wide temperature range for at least 72 hours, although there was some loss of viability of lactobacilli on prolonged storage at room temperature or 37 degrees C in one experiment. Rising samples yielded higher counts than samples collected after breakfast and toothbrushing. Day-to-day variability was considerable, with 95% confidence limits exceeding 1 log in 28% of data sets for MS count and 39% of data sets for Lactobacillus.

Longevity of restorations in a dental school clinic

The longevity of 1,207 restorations placed by students was studied in 70 adult patients. The overall percentage of restorations lasting ten years or more (P10) was 75.4 percent and survival times were longer than in most previous restoration longevity studies. Cast restorations lasted significantly longer than amalgams, which in turn lasted significantly longer than composites. P10 values were 91.1 percent, 72.0 percent, and 55.9 percent, respectively. Analysis by surfaces involved indicated that single-surface lasted longer than multisurface restorations. The survival of restorations placed in patients aged 60 or more was less favorable (P10 = 56.8 percent) than for younger patients (P10 = 78.3 percent). A subset of the population was identified on the basis of a restoration failure rate of greater than 4.0 X 10(-2) failures/restoration year. This group, comprising 18.6 percent of the population, accounted for 56.1 percent of all restoration failures. The P10 value for this high-risk group was 55.8 percent, as compared with 83.9 percent for the remainder of the population.